British women have more control over their bodies than ever before. Just over 50 years ago, hormonal contraception was virtually non-existent. The majority of women married and had families at an early age.

It was only in 1961 that the pill became available on the NHS – a move hailed as the beginning of sexual emancipation. But, even then, prescribing of the contraceptive was mainly limited to older, married women who already had children. It took until 1974 for family planning clinics to be able to prescribe it to all women, regardless of marital status, for free – a controversial decision at the time.

Today, sexual emancipation has arguably arrived. Women can choose from a plethora of contraceptives, dedicated clinics and advice centres. The arrival of emergency hormonal contraception (EHC) – or the morning-after pill – has given women even more control over their fertility. But one barrier remains: in some cases, it isn’t the woman who chooses whether to fill a prescription for EHC but her pharmacist. 

This all comes down to standard 3.4 in the General Pharmaceutical Council (GPhC) standards of conduct, ethics and performance – otherwise referred to as the conscience clause. As the name suggests, this clause gives pharmacists an opt-out for any services and medicines that are contrary to their “religious and moral beliefs”. Unlike nurses, it means they can refuse to provide EHC, as long as they refer the patient to another provider.

The discrepancy between pharmacists and nurses has understandably prompted questions. When the GPhC came into operation in 2010, it held a consultation on its code of ethics. A number of respondents gave views on standard 3.4 in particular – with many suggesting that pharmacy professionals should set aside their personal beliefs if it was in the best interests of the patient. There were also concerns that those seeking the services of a pharmacist “might be vulnerable” and the refusal to provide EHC could prevent the patient from seeking assistance elsewhere. 

The debate is just as relevant today. The GPhC is set to conduct a wider review of ethical standards in late 2015 or early 2016 – and it seems public opinion is in favour of standard 3.4 coming under the microscope.

Although the regulator does not collate information on the number of complaints it has received regarding refusal to provide EHC, it revealed that a recent patient focus group raised the issue of whether a pharmacist’s beliefs should influence the services they provide. This opinion could prove a deciding factor as to whether pharmacists will be able to continue to make conscientious objections as they do today.
 

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“Like everything else, morality is not a fixed thing – what was immoral in the 1950s is legislated for in 2015. You find conservative people will cling to old standards and fight furiously to maintain some control” Terry Maguire

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Patient first

The objections to EHC may seem as old-fashioned as the resistance to the pill in the 1960s. Like the pill, its aim is to prevent a pregnancy rather than to terminate one. Depending on the point at which it is taken in the menstrual cycle, it will prevent or delay ovulation, prevent fertilisation or prevent implantation of the fertilised egg into the uterus.

And, like the pill, Northern Ireland contractor Terry Maguire believes EHC will become more and more normalised. Arguably, this will render its place in the conscience clause irrelevant.

Pharmacists in Northern Ireland once conscientiously objected to supplying the pill, points out Mr Maguire, owner of Maguire's Pharmacies in Belfast. They could technically do so today – a pharmacist can object to any service – but it is rarely an issue. “Like everything else, morality is not a fixed thing – what was immoral in the 1950s is legislated for in 2015,” he says. “You find conservative people will cling to old standards and fight furiously to maintain some control.”

Mr Maguire sees objections to EHC as largely being in the past. He believes a “very small minority” of pharmacists have problems providing the morning-after pill today. “In reality, a sizeable proportion of our profession recognises the responsibilities and will address them to the best of [their] ability,” he says. 

That doesn’t mean he is in favour of keeping the conscience clause as it is. “I think the conscience clause] will go,” he says. “It will run its course and there will be a generation that views things in a totally different way.” Ultimately, Mr Maguire believes professionals should act in the best interests of their patients. 

This question of patient interest is particularly important in the case of EHC, which is a time-sensitive medication. In the case of Levonelle, it is most effective within the first 24 hours and it must be taken within 72 hours to have a chance of working. In 2012, GPhC guidance specified that pharmacists who refuse to supply EHC must ensure that the patient is able to access it from another provider within the timeframe. But the delay could increase the chance of an unwanted pregnancy. This possibility isn’t just theoretical – in 2005, a Cardiff couple announced they were expecting their first child after their local pharmacist refused to dispense the morning-after pill.

This element of patient need hasn’t escaped Jignesh Patel, owner of Rohpharm Pharmacy in Plaistow, London. He recognises that some pharmacists may feel that supplying EHC goes against their religious beliefs, but stresses that the health and wellbeing of patients must be paramount. 

“In any religion, do we look to our own personal beliefs, even when it is detrimental to the health of the individual, or do we look at the wellbeing of the individual?” Mr Patel says. “For me, the wellbeing of the patient is the most morally important part of the services healthcare professionals can provide.”
 

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“For me, the wellbeing of the patient is the most morally important part of the services healthcare professionals can provide” Jignesh Patel

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‘No simple answer’

But for everyone who feels the right to refuse EHC is outdated, another person will defend its existence. A C+D poll of 370 readers in August revealed just how divisive the issue is – 47% of readers thought pharmacists should be able to conscientiously object, while 53% were against the clause. This figure has barely changed from a similar poll conducted in 2012. 

Krishan Mahil, a locum based in the north west of England, was one of those who voted in favour of the right to refuse EHC. Although he would always provide it and thinks other pharmacists “should do so when necessary”, he questions whether its supply should be mandatory. “It’s a complex issue with moral, ethical and religious components and I don’t think there is a simple yes or no answer,” he says. 

Gerry Diamond, medicines optimisation pharmacist at a Blackpool health centre, voted the same way because he believes that pharmacists who have religious objections should maintain their right to refer to another provider. 

It is fair to say that the supply of EHC doesn’t sit easy with all pharmacists. Eoghan O’Brien, owner of Bannside Pharmacy in County Antrim and winner of C+D Public Health Initiative of the Year 2015, has experienced doubts over its ethical implications. “I know at times I have questioned myself a little bit but I have always supplied EHC,” Mr O’Brien explains. For this reason, he believes pharmacists should have the right to refuse it, as long as they “take the patient’s needs into consideration”.

It seems that even family planning clinics can understand this point of view. The British Pregnancy Advisory Service (BPAS) tells C+D that the personal beliefs of healthcare staff can be respected – on the condition that it does not impact on the women seeking contraceptive care. “Pharmacists who object to dispensing the drug must be conscious of the fact that any delay increases the risk of unplanned pregnancy,” it stresses. “They must refer the patient to someone who will [provide it] as a matter of urgency.”

Crucially, the BPAS says professionals who conscientiously object must treat women accessing “this safe and effective” method of contraceptive with the care and respect that they deserve. This need for patient respect is perhaps another argument in favour of the conscience clause.

Forcing all pharmacists to supply EHC could arguably leave more women open to cases such as that of Piotr Mikolaj Majchrowicz, registration number 2069549, who subjected a patient to a “distressing lecture” in 2012. Unhappy about supplying the morning-after pill, he told the patient she was "ending a life" and that the decision would be "on her conscience". When he was brought in front of the GPhC fitness-to-practise committee, Mr Majchrowicz was given a three-year ban on providing EHC – he is now resigning from the profession due to his strong stance on the issue.
 

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“Pharmacy owners may find themselves in breach of their NHS terms of service obligations if they fail to supply prescribed medicines ‘with reasonable promptness’” Noel Wardle

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A tough decision

With strong feelings on both sides of the conscience clause, it is difficult to predict how the GPhC will proceed in its review of ethical standards. Noel Wardle, partner at law firm Charles Russell Speechlys, points out that standard 3.4 has “caused controversy for some time” and the GPhC has been under pressure to review the clause since its establishment in 2010.

Mr Wardle highlights the media storm that year over a Sheffield pharmacist who denied a woman the morning-after pill and told her to return the following day when another pharmacist would be on duty – clearly problematic considering the pills are highly time-sensitive. 

Incidents such as these could clearly damage public perceptions of the profession. But the clause could also have a negative effect on pharmacy owners, Mr Wardle warns. He points out that it can cause “logistical headaches” for contractors trying to identify pharmacists to work in particular pharmacies and also leave them open to contract breaches. “Pharmacy owners may find themselves in breach of their NHS terms of service obligations if they fail to supply prescribed medicines ‘with reasonable promptness’," Mr Wardle explains. 

All of these possibilities aside, Mr Wardle believes the regulator is “unlikely" to scrap the clause unless there is a significant negative event. “If the clause is removed, then it may have an effect on pharmacists who do not wish to supply medicines such as the morning-after pill,” Mr Wardle said. “For pharmacists who chose the profession at least in part because they would not be forced to supply such medicines, a change in their ethical obligations may cause them to rethink their chosen profession.”

The debate over the conscience clause won’t be resolved easily. On one side, maintaining the status quo could have a negative impact on patients and the image of the profession. On the other side, abolishing the conscience clause could be seen as an infringement of religious and moral freedoms. 

Amid all this uncertainty, perhaps the most important thing to bear in mind is the pharmacist’s role as a healthcare professional. So when a patient requests your services, including EHC, the question to bear in mind is this: will this decision be compatible with my role as a caregiver?